Reprint from American Journal of Surgery. 
Excision of Tubercular Knee 
Joint. 
A CASE OF INCIPIENT HIP-JOINT DISEASE. 
BY 
H. AUGUSTUS WIUSON/ M. D. 
PHILADELPHIA, PA. 
Clinical Professor of Orthopaedic Surgery, Jefferson Medical College. 
H.-K. Pub. Co., K. C. EXCISION OF TUBERCULAR KNEE JOINT. 
A CASE OF INCIPIENT HIP-JOINT DISEASE.* 
BY H. AUGUSTUS WILSON, M. D., 
PHILADELPHIA, PA. 
[Clinical Professor of Orthopaedic Surgery, Jefferson Medical College.] 
Gentlemen:—The first case I bring before you to-day is a woman, 25 
years of age, who says that nineteen years ago. or when she was six years 
of age, some trouble of the knee-joint began, although the nature of this 
trouble she is unable to tell. For twelve years past, the knee has been 
more or less bent, gradually increasing, and during the last two years it 
has become more and more so, until now it is in a right angled position. 
For a time she walked upon her leg by using a high sole, but for the past 
two years she has not been able to walk upon it at all. One year ago a 
sinus appeared on the outside of the knee, and a discharge began which 
has continued up to the present time. 
It is of interest to get at the pathological condition which may have 
caused an injury of this kind, and to that end, inquiry has elicited the 
following: Her father died of phthisis ; four sisters and two brothers died 
in infancy from conditions which would indicate inherited tubercular 
diathesis. Here is sufficient history of tuberculosis to give a diagnosis. 
The case is of special interest because it shows the character of the dis- 
ease—how it may run for years without the formation of sinuses. The 
chronic character of this tubercular bone affection must be impressed 
upon you that you may know the long, tedious character of the treat- 
ment required to secure a good result. In these cases, we are able gen- 
erally to secure a history of tubercular disease of the hard or soft tissues 
in parents or families, and it generally means a less favorable subject for 
operation. In this case we expect to do enough to thoroughly eradicate 
the local diseased tissue. I would like you to notice the backward dislo- 
cation of the tibia, the prominence oi the condyles, and the position of 
the sinuses. Is it possible by means of forcible straightening to correct 
this deformity after simple division of the tendons? If this is possible, 
what shall we do with the foci of the disease? If we simply divide the 
contracted soft tissues and attempt to gouge out the carious mass by en- 
larging the opening, we would not get a good result, as we could not 
reach all the disease, and the mere removal of a part only, would not be 
efficacious. Excision of the joint is the proper method of procedure, 
with removal of all the necrosed tissue, so that ossific union may result. 
How, now, shall we proceed with the excision ? The methods, ordinarily 
resorted to, are three principally: The first is to take the condyles as 
the beginning and ending point of the incision, and then, by one ot two 
methods, have the incision connected with these two points. Either let 
the line of incision pass directly across the center of the patella, or let 
it pass by a circular line, the lowest point of which is at the middle of 
the ligament of the patella. In either of these incisions you are enabled 
to retract the flap sufficiently to see, and remove, the necrosed tissue, 
"Clinical Lecture delivered at the Jefferson Medical College Hospital. Tubercular Joints— Wilson. 
3 
To avoid the occurrence of posterior displacement of the tibia it is 
recommended that a direct vertical incision be made over the patella 
which may be extended through the patella by means of a saw, and 
through the quadriceps muscle, there exposing the condyles which maybe 
removed. A point in favor of this vertical method is that it is a very rare 
thing to have bony union in transverse fracture of the patella, and hence 
by this operation, which results in a vertical fracture of the patella, the 
bony union is facilitated. The obstacles to bony union of transverse 
fracture of the patella are, first, the entrance of the synovial fluids be- 
tween the fragments; second, the difficulty of keeping absolute coapta- 
tion of the fragments, and third, the rupture of the nutrient artery of the 
patella, and thereby diminishing the nutrition of the patella. If the pa- 
tella can be so divided that bony union will take place, we then have a 
strong anterior splint to prevent the posterior dislocation, to which I have 
already referred. 
Here is a pathological specimen of a right-angled ankylosis of the 
knee-joint, and you will observe that the patella is firmly united by ossific 
deposit, and that the vertical incision would not only not facilitate, but 
would add greatly to the difficulty of the operation in such a case. 
Hence, at times, it becomes necessary to resort to other modes of incision. 
If our case had the extensive lesions found in this specimen, a large mass 
of tissue would have to be removed in order to excise all unhealthy 
structures. By means of this articulated knee, I want to show you one 
or two important points in excision of the knee-joint. After dividing the 
soft tissues, we proceed to saw off the diseased bony tissue. If this is 
done by the ordinary butcher’s saw, at a right angle to the center line of 
the femur, we will produce deformity by the obliquity of the 
point of contact of the femur and tibia. We must make our incision 
with the saw, in a line parallel to the articulation, and at a right angle to 
a line drawn from the center of the ankle joint, to the center of the head 
of the femur, and not at right angles to the femur. If we cut from with- 
out, inward, there is a possibility that the popliteal space may be invaded, 
with the risk of injuring the popliteal vessels. This may be avoided by 
means of a rubber or tin plate, which can be slipped under the condyles. 
I prefer hard rubber for the reason that when it is put into hot water, it 
becomes malleable and can be readily curved to suit the case and passed 
under the condyles. Now, in removing the diseased head of the tibia, 
the same precautions must be taken to prevent a crooked leg resulting. 
Then the question arises, “ How shall we hold the excised ends of the 
femur and tibia together?” Various methods have been resorted to, as 
suturing with cat-gut through holes bored through the ends of the bones. 
The objection to cat-gut is, that it is apt to yield too soon. One of the 
methods employed in this hospital is the insertion of nails, which are 
driven into the cancellous structure of the bone, thus holding the bones 
fixed in a proper position. They are perfectly innocuous if they are ren- 
dered aseptic before using, and they may be removed by a rotary move- 
ment, five or six weeks after the operation. The use of wire has been 
recommended, and may be used by means of small nails which are placed 
in the ends of the bones, copper or silver wire being wrapped around 
them. This method requires a greater incision afterwards in order to 
withdraw the nails and wire. The use of an}7 internal method of main- 
taining co-aptation may be dispensed with, when a properly constructed 
splint is employed, and as there is less danger of inflammation, reliance 
should be had upon the splint. Esmarch’s bandage has been employed 
in order to secure a bloodless operation, and it renders the operation 4 
Tubercular Joints— Wilson. 
field very clean and facilitates the finding of the nidus of the disease, but 
secondary haemorrhage is apt to follow, or at least a considerable amount 
of oozing, whereas, if we proceed without the Esmarch’s bandage and 
control haemorrhage with haemostats, and ligate all bleeding points, we 
have almost as dry an operation and as good a result, without the possi- 
bility of secondary bleeding. The use of the Esmarch’s bandage makes 
it possible to work more rapidly at the time of the operation, but we lose 
time afterwards. Where the Esmarch’s bandage is not used, it is possible to 
close the wound aseptically and leave it undisturbed for a period of four 
to six weeks; this is rarely possible when Esmarch’s bandages has been 
employed. The usual results of excision of the knee-joint are, no rise of 
temperature and no dressing required from four to six weeks. Then 
comes the most critical point in the treatment of the case. The union 
of the parts is not always as firm as after fracture, and if the patient be 
allowed to use the limb, the parts are apt to become distorted. If the 
patient be kept on the back longer than this, and then be put on crutches 
for six or eight weeks more, a more perfect result will be obtained. 
There is one other method I wish to speak of and this is not applicable 
to this case, although it is frequently employed where there is no caries 
of the bone. It consists in abrasion of the joint surfaces. After expos- 
ure of the joint, all of the cartilage and articular surfaces are abraded by 
the back or handle of the knife, and put to rest in the extended position 
and there results ankylosis without shortening. It is not applicable here 
because a considerable amount of necrosed tissue must be removed. 
The plan of procedure I shall adopt in this case, is the circular flap, 
starting the incision at the sinus over the external condyle, sweeping the 
knife downward through the middle of the ligamentum patellae and carry- 
ing it around to the inner condyle. Dissecting up this flap, I can now 
proceed to divide the ligament of the patella and now find that the pa- 
tella is ankylosed in between the condyles, • necessitating the use of the 
chisel to cut it loose. By the use of the saw, I am able to remove all of 
the necrosed tissue from the head of the tibia and, likewise, from the 
end of the femur, without removing too much material. Extending the 
leg, I now adjust it to its future position and find that the lines of incision 
were correctly made for co-aptation is accomplished in a correct position. 
The caries of the patella has been so extensive that I deem its removal 
essential, and shall proceed to cut out the entire tract of the former sinus. 
I shall use four steel nails, three inches long to maintain co-aptation. 
Rubber drainage for twenty-four hours will be employed and removed at 
the next dressing. The skin wound will be held in contact, with silk 
worm gut, and apply the usual aseptic dressing. The form of splint to 
be used in this case, will be an impromtu one made of plaster of Paris 
and two bent iron bars, and possesses the advantage of rigidly maintain- 
ing the proper position and facilitating the removal of drainage and re- 
dressing. The first step is to apply the plaster of Paris bandage from, 
and embracing the foot, to a few inches below our incision, and an- 
other one from just above the knee, embracing the thigh and extending 
on the outside, above the hip. As soon as these are firmly set, I adjust 
the lateral iron bars to fit, and they are as you see, bent out so as to 
leave ample room around the knee. While an assistant holds these two 
lateral bars in the proper position, and another holds the leg in the posi- 
tion that we wish to have it remain, I will apply a plaster of Paris band- 
age covering the ends of the bars, and thus make a splint well adapted 
to the case. Tubercular Joints—Wilson. 
5 
I bring before you a little girl, aged 7 years, that will illustrate the 
manner of making a diagnosis of hip disease, and I wish to impress every 
motion upon you, for the diagnosis will be made, almost entirely, by 
watching for defective movements. The child gives very meagre his- 
tory, and in its very vagueness, you will observe the necessity of care- 
fully studying the most minute details: No one symptom or sign can be 
considered pathognomonic, but it is the association of groups that we 
are able to decide what conditions are present, and therefore what form 
of treatment is applicable. During the past two weeks the mother says 
there has been some limping but the child has never complained of pain. 
She does not always limp, but it is more apparent after she has become 
fatigued from walking. Sleep is not much disturbed; she does not ap- 
pear to be any more restless than the other children in the same family. 
She has always been a fairly healthy child, having had the measles but 
no other diseases of childhood. Upon close inquiry, I have learned that 
the family has a history of phthisis upon the mother’s side, an aunt and 
uncle of the patient having died of phthisis. The only symptom of any 
kind that can be obtained, is the occasional limping when the child is 
fatigued, and with that one symptom, it will be necessary to subject the 
case to that critical inspection, always to be observed in the diagnosis of 
any supposed tubercular joint disease. There is no certainty that a joint 
disease is present, for the limping may be accounted for, by a short leg, 
by muscular atrophy or by a sprain, reflex irritation or spondylitis. But 
the family history naturally attracts our attention to the joints, and as 
you preceive, there is as yet nothing to attract our attention to any of the 
joints. The beginning of these affections are not heralded with gross 
manifestations of severe pain, immediate deformity, inability to use 
the parts, but the invasion is most insidious and, therefore, considerable 
discernment is necessary to locate the lesion in its incipiency. One of 
the points I want you to observe is the possibility of making an accur- 
ate diagnosis almost without touching the patient. This is accomplished 
by asking the patient to assume those positions which will manifest any 
departure from the normal mechanical functions of the joints. The pa- 
tient being nude is now requested to walk about, to stoop, to sit down, 
and you observe a normal freedom of action of the vertebral column, so 
that we may safely exclude that from our further consideration. The limp is 
not that which is associated with acute pain, nor is it apparently due to 
soreness, but is the kind of limp dependent upon restriction to motion. 
In walking, the weight of the body rests upon the left foot for a precep- 
tibly shorter time than upon the right, the steps are not even or regular, 
but it is one long and then one short step, the left side being less used 
than the right. We have now located the lesion of whatever character 
it may prove to be, to be upon the left side, and placing the patient upon 
a bed, we will proceed to criticise the motions of the ankle joint and then 
the knee and finally the hip. The child produces perfectly free move- 
ments of the ankle flexion, extension, the normal amount of rotation, and 
the lateral movements are unimpaired. The patient now being placed 
so that both legs may be flexed over the edge of the bed, she is requested 
to extend the leg of the right side and then of the left fully. This she 
does with ease, and following it with extreme flexion demonstrating an 
absence of any restraint. The knee being a simple ginglymoid joint it is 
very easy to discover any loss of function, but not so with the compli- 
cated ball and socket joint of the hip to which your attention must now be 
A CASE OF INCIPIENT HIP-JOINT DISEASE. 6 
Tubercular Joints— Wilson. 
directed. There is nothing apparent, on inspection, save that the super- 
ficial veins on the left side are somewhat engorged and swollen. The 
left leg, you will bear in mind, is the one affected, but I start with the 
other side, in order to accustom the child to the motions and manipula- 
tions to which she will be subjected, and as well that a comparison may 
be made between the sound and the affected leg. The child is now re- 
quested to draw up the right leg, so that she can touch her knee on her 
chin, without using her hands to assist the movement of the leg, and you 
see that there is a free motion on this side. 
Repeating now the same procedure on the left side, it is clearly mani- 
fest that there is marked difficulty in flexion, and that this is made still 
more apparent when the child attempts to flex both legs at the same 
time. 
To examine extension, it is essential that the patient should be 
placed upon an even surface, like this operating table which is covered 
only with a blanket, for the depression of the body in a bed would prevent 
you from observing, or even obtaining, the full extension that you seek. 
The position that the child selects is slight flexion of the left hip and full 
extension of the right, and in this position, the lumbar vertebrae touch 
the table, which you observe arch sufficiently to enable me to pass my 
hand, when the left leg is fully extended. With both legs apparently fully 
extended, you will observe the same thing which is due to restraint to 
full extension of the hip joint and to the tilting up of the pelvis made 
possible by the compensatory joint formed by the lumbar spine. So now 
we have evidence of impaired flexion, and impaired extension. 
To properly observe abduction and adduction, it is necessary to have 
the patient place her heel upon your hand and then to thoroughly relax all 
her muscles, permitting you to gently abduct and adduct. This being 
done like the previous movements upon the right side first, the full con- 
fidence of the child is obtained. The indicators to be watched are the 
anterior superior spinous process of the ilium of the opposite side as an 
indicator of gross movements, and the genitalia upon the same side, as 
the movements are made, as a finer test. Thus in abduction and adduc- 
tion you observe that these indicators move in the same direction as the 
affected leg, which was not the case when the right leg was being ob- 
served. This means that there is impaired abduction and impaired ad- 
duction, and when the full limit of motion is reached, that is possible in 
the hip joint, then the supplemental joint, formed by the lumbar vertebrae 
again comes into play, and enables the pelvis to move in the same direc- 
tion as the affected leg. 
Ret us see now how far there is restriction to rotation, to accomplish 
which, the child will be requested, while upon her back, to put the right 
leg into the shoe and stocking position, with the external malleolus of 
the right leg on the patella of the opposite side and to depress the right 
knee. This movement requires extensive rotation for its accomplish- 
ment, and she accomplishes it with utmost ease, but how impossible it is 
for her to do the same thing with the left leg. She can, after a fashion, 
put her left external malleolus upon the right knee but it is done by ad- 
ducting the right knee, and even then she cannot depress the left knee 
because of an absence of rotation in the acetabulum. Now we have im- 
perfect rotation added to the other evidence of impaired mechanical 
function. Much can be learned from observing the manner in which she 
turns herself, for she guards the affected side with an instinctive care that 
tells its own story. There is a great deal too much importance attached Tubercular Joints— Wilson. 
7 
to the illiofemoral crease as a diagnostic factor. It depends upon mech- 
anical conditions which are easily diagnosticated, and I rarely find it of 
any use because having found those conditions which produce the 
changes in it, I require no further proof. On the left side it is slightly 
diminished, and yet, were you to take that as an evidence of disease, you 
would be deceived, since it is entirely due, in this instance, to the position 
of the child. Now as she lies fiat upon her face, the crease is slightly in- 
creased. If this child were to make strong efforts of the gluteal muscles 
on this side, it would efface the crease; it therefore depends upon the 
mechanical condition of the joint, and not so much on an inflammatory 
condition. As she moves over to her back again, she again guards the 
left leg with great care, confirming the observations already made. 
A methed too frequently resorted to, in making a diagnosis, is to 
pound upon the heel while the affected leg is extended, or upon the 
flexed knee, which, if followed by a shriek of agnoy, is considered con- 
firmation. I cannot too strongly deprecate the resort to such a brutal 
method of procedure, for it is of absolutely no value further than to 
demonstrate that the child may be forced to experience pain, by inflicting 
traumatism upon a joint already inflamed. If you apply your skill, you 
may easily discern the presence of inflammatory processes and finding 
this, you will know that there must be pain as an associate but you need 
not resort to force to prove it, especially in view of the fact that the ap- 
plication of such force is productive of more damage to a tubercular 
joint, than can be overcome in months of most carefully applied treat- 
ment. It would be just as scientific, just as practical, just as rational and 
of equal value, to punch the abdomen of a case of peritonitis and blandly 
ask, does it hurt? These incipient tubercular joint diseases may go on 
for some time without manifesting other symptoms than that found in 
this patient, and is illustrative of slow action. Again in some instances, 
the progress is very rapid, proceeding often from a blow or a fall, to 
rapid disintegration and abscess, clearly indicating the necessity of early 
immobilization and freedom form injury. 
Now I shall measure from the points of the anterior superior spinous 
processes, with the child lying in a straight position on its back, in order 
to observe the presence or absence of inequality in the length of the legs. 
Uet me show you how to avoid errors in measuring the length of the 
legs. Taking the tape measure in my hands, I hold my finger of one 
hand at a fixed point at the inner malleolus, I can allow my finger of the 
other hand to slide over the anterior superior spine while still on a fixed 
point on the. skin, and thus apparently increase the length of the 
limb one inch. This is one of the sources .of error in taking measure- 
ments, and to illustrate its inaccuracy, I find the affected leg apparently 
one inch longer than the sound one, while there is absolutely no differ- 
ence. Uet us now group what we have, and endeavor to not only locate 
the lesion but to decide as to its character. Until this has been accom- 
plished, a consideration of the treatment would be futile for we would 
not know for what condition the treatment should be applied. The child 
has limped for two weeks, has had no pain, sleeps fairly well, is not rest- 
less. All the joints in the body are normal in their action except the 
left hip joint, which has limited flexion, extension, and an almost entire 
absence of rotation. A point has now been reached when a positive de- 
cision must be reached, and upon this decision will depend the future of 
the case. Shall the hip be immobilized or attempts made to increase the 
motion? There is abundant evidence of the presence of ostitis to form an 
accurate diagnosis of incipient hip joint disease and the very clear indica- 8 
Tubercular Joints— Wilson. 
tions are to put the affected part at rest at once. To accomplish this, the 
child will be placed in bed with extension of one pound applied to the 
leg by means of adhesive plaster, sand bags reaching from axillae to feet 
will be applied upon each side of the patient. Let me urge you to insist 
upon contionuous immobility and that the good accomplished by it is not 
counter balanced by use, on the part of the patient or by the nurse, when 
the bed pan is used. The nurse plays a most important part in the treat- 
ment, for she can easily spoil all that has been done, by permitting mo- 
tion of the hip, or when making the bed or washing the patient. Absolute 
and continuous immobility is required, and unless this is accomplished, 
there is no necessity of keeping the child in bed, it might just as well 
run about. In fact the inefficiency of the bed treatment not onfy brings 
reproach upon the method, but tends to a postponement of operative 
procedure having for its object, the removal of the carious points. 
This is just the stage of the disease that you want your cases to come 
under treatment, in order to have the best results. If this limb is re- 
stricted in its motion, you will have a good limb result, without any per- 
manent restriction of motion. The temperature of the child at present, 
in the-mouth, is 983-5, not indicative of any fever. The essential points 
in this case are, first, the extreme difficulty with which we make a diag- 
nosis in the early incipient stage ; second, the disease is an insidious one and 
advances by slow stages, and if we get at the cases later than this, the 
treatment will not be so satisfactory. Compare the two cases of tuber- 
cular bone disease seen to-day, one coming eighteen years after the be- 
ginning of the disease, with sinus formed and discharging, and the other 
in the first stage of the disease; the one comes for a correction of a de- 
formity; the other, for the prevention of a deformity that will inevitably 
result if the full importance of the case is not impressed upon us.